Diabulimia describes the practice of purposefully reducing or omitting in order to lose weight and is incredibly dangerous. It can result in increased and earlier complications of and reduce both life expectancy and quality of life. There is a lack of awareness of diabulimia amongst family and friends of people with and amongst healthcare professionals who do not necessarily consider it as a cause for recurrent Diabetic (DKA) or persistent hyperglycaemia. Added to this, there is a lack of access to specialist care and treatment.

This position has been influenced by our knowledge gained from consulting with experts, people with diabetes and reviewing the latest evidence and guidance.

We recommend that awareness of signs and consequences of diabulimia must be raised with friends and family of people with Type 1 diabetes, and with healthcare professionals.

Standard treatments for eating disorders are not usually appropriate for cases of diabulimia and can be ineffective and potentially harmful. Access to specialist care is vital and access to specialist treatment and support needs to urgently improve in order to reduce the number of people who develop serious complications of diabetes and a severely reduced quality of life due to diabulimia.

Recommendations

Healthcare professionals, family and friends of people with Type 1 diabetes should be aware of the signs that could indicate diabulimia.

Healthcare professionals should be given sufficient time, resources and training to identify and support people with diabulimia.Psychological factors including diabulimia, should always be considered, assessed and excluded in all episodes of DKA.

Diabulimia requires careful treatment from a team of specialists and healthcare professionals should refer to specialist services without delay.

With difficulties in establishing prevalence data there is a need for more research into effective screening of the condition and research into effective treatment.

Deliberately and regularly under dosing or omitting insulin to purge calories to lose weight is a disordered eating behavior unique to individuals with Type 1 diabetes referred to as diabulimia by those who practice it(1) and recognised in NICE guidance for eating disorders(2). Eating disorders have the highest mortality rate of any mental illness (3) and diabulimia is incredibly dangerous. People who restrict insulin in this way are at higher risk of the short and long term complications of diabetes, reduced life expectancy, a threefold increase in mortality and reduced quality of life (4-6).

There is a lack of awareness of diabulimia amongst family and friends of people with Type 1 diabetes and amongst healthcare professionals who do not necessarily consider it as a cause for recurrent (DKA) or persistent hyperglycaemia. Signs that can indicate diabulimia include recurrent DKA, hyperglycaemia requiring admission to hospital, or weight fluctuation, regular symptoms of high blood glucose levels and early onset of diabetes complications(7-8).

Men and women can be affected by diabulimia. It is difficult to quantify the prevalence of diabulimia as different methodology is used but conservative estimates of insulin omission have been reported in up to 40% of people with type

1 diabetes . Individuals with diabetes compared to those without are at heightened risk for developing comorbid eating disorders with approximately 30% of women and 20% of men with Type 1 diabetes reporting comorbid disordered eating behavior(10). A systematic review suggested approximately three quarters of individuals omitting insulin reported other disordered eating behaviors such as self-induced vomiting and excessive exercise (11).

The recommended management of Type 1 diabetes can make an individual more vulnerable to eating disorders and though it is unlikely the diabetes specific causes exist by themselves and diabulimia usually develops from a complex combination of biological, psychological and social difficulties.

NICE has management guidance for people with an and diabetes with recommendations for eating disorder and diabetes teams. It highlights the need for collaboration and need to address insulin misuse as part of any psychological treatment for eating disorders in people with diabetes (2).

NICE recommend that for children and young people with type 1 diabetes For children and young people with type 1 diabetes in whom eating disorders are identified, offer joint management involving their diabetes team and child mental health professionals(12).

Support for people with diabetes With the right help and support, diabulimia can be overcome. The national charity DWED www.dwed.org.uk was set up to directly address diabulimia and other eating disorders in those with Type 1 diabetes where you can access useful information and there is an online forum where you can chat to others in the UK. We also have our own helpline with trained counsellors who can listen and help(13).

Support for healthcare professionals

The national charity DWED www.dwed.org.uk has useful information and you can request training